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Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

Documentation Tip: Audit Protection

Official coding guidelines support coding a diagnosis that is only documented once in the medical record. However, auditors increasingly deny diagnoses that do not flow consistently through the medical record to include the discharge summary. While it is not necessary for a physician to document the criteria used to make a diagnosis, it will reduce the potential for denial. Conflicting documentation between different providers increases the likelihood of denial. Whenever possible, the attending physician should clarify any inconsistent documentation.

ABOUT THE AUTHOR

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.